The Brazilian version of the High-Activity Arthroplasty Score: cross-cultural adaptation

ABSTRACT BACKGROUND: The High Activity Arthroplasty Score (HAAS) is a self-administered questionnaire, developed in British English, that reliably and validly measures the levels of sports activities in patients following hip and knee arthroplasty surgery. OBJECTIVE: To cross-culturally adapt the HAAS to Brazilian Portuguese language. DESIGN AND SETTING: A cross-sectional study was conducted at a public university hospital in Brazil. METHODS: The Brazilian version of the HAAS was created through a six-step process: translation, synthesis, committee review, pretesting, back-translation, and submission to developers. The translation step was conducted by two independent bilingual translators, both native speakers of Brazilian Portuguese. The back-translation was performed by an independent translator, a native speaker of British English. To ensure the questionnaire's comprehensibility, 46 volunteers (51% men; average age 34-63) participated in the pre-testing step. RESULTS: The cross-cultural adaptation process necessitated modifications to certain terms and expressions to achieve cultural equivalence with the original HAAS. CONCLUSION: The HAAS has been translated from English into Brazilian Portuguese and culturally adapted for Brazil. The validation process for HAAS-Brazil is currently underway.


INTRODUCTION
The functional outcome of hip and knee arthroplasty can be evaluated using health-related quality of life instruments, such as questionnaires and scales.[3] The focus on pain and DAs presents a challenge in identifying individuals who exhibit no pain limitation during low-demand activities, including DAs, but experience limitations during more strenuous activities, such as sports. 4Current instruments fall short in assessing significant

Type of study
This is a cross-sectional, quanti-qualitative study focused on the cross-cultural adaptation of a questionnaire.The primary data was collected between September 2021 and August 2022.
The ethics committee of Hospital Universitário Pedro Ernesto, affiliated with Universidade do Estado do Rio de Janeiro (UERJ), granted approval for this study on August 30, 2021 (approval number 50529321.3.0000.5259).All participants provided their informed consent.Dr. Simon Talbot, the primary author of the HAAS, granted permission for its cross-cultural adaptation into Brazilian Portuguese on December 28, 2020.

Cross-cultural adaptation
To adapt the HAAS, we adhered to the guidelines suggested by Beaton et al. 5 with further considerations by Borsa, Damasio, and Bandeira. 6The procedure encompasses six steps: translation, synthesis, review by committee, pretesting, back-translation, and submission of documentation to the developers (Figure 1).
Step 1: Translation The HAAS was initially translated from English to Brazilian Portuguese by two independent translators, both native speakers of Brazilian Portuguese and fluent in English.This process resulted in two distinct Brazilian Portuguese blind translations: T 1 and T 2 .
Step 2: Synthesis Two native Brazilian Portuguese speakers, residing in Brazil, synthesized T 1 and T 2 into the Brazilian Portuguese language.
A reconciled version, T 1,2 , was created, and the entire process was duly documented.
Step 3: Review by a committee A multidisciplinary committee was formed to review T 1,2 , comprising experts in the construct under evaluation and cross-cultural adaptation studies.This committee included one physiotherapist, two orthopedists, and two physical educators.
Additionally, one committee member held a degree in Language, specializing in translation and communication.
The aim of this step was to assess the semantic, idiomatic, cul- Step 4: Pretesting The objective of this step was to determine whether volunteers found the V 1 items, instructions, and response scale comprehensible.The Three-Step Test-Interview (TSTI) employing a 5-item Likert Scale was utilized to evaluate the questionnaire's adaptation. 8,9The sample size was established using the saturation criteria technique. 10e results of the pretesting were analyzed through a qualitative assessment, taking into account suggestions for improved adaptation and comprehension from the volunteers.This process led to the creation of a final version (V f ).
Step 5: Back-translation Back-translation can be utilized to assess whether the conceptual equivalence between the synthesized and revised V f and the original instrument has been preserved.This process facilitates the evaluation of the culturally adapted instrument by its developers. 6e back-translation was conducted blindly by a native British English speaker who is fluent in Portuguese but lacks technical knowledge of the study's subject matter.The entire process was meticulously documented in writing.

Step 6: Submission of documentation to the developers
The aim of this step was to present the Brazilian version of HAAS to the original developers.Step 1

Translation
Step 2

Synthesis
Step 3

Review
Step 4

RESULTS
Step 1 produced two independent translations: T 1 and T 2 (Box 1).
The synthesis of T 1 and T 2 produced T 1,2 (Box 2), that was evaluated and reviewed by the multidisciplinary committee on the third step.
The main modifications proposed by the committee are listed in Table 1 and Table 2.The qualitative analysis undertaken by the multidisciplinary committee of specialists was guided by the CCV. 7Items in which CCV was below 0.8 were modified by the committee prior to pretesting.Grammar, typing, and formatting errors were revised as part of this step.As a result, a version (V 1 ) for pre-test was produced (Box 3).Minimal modifications were proposed for the final version (V f ), which was subsequently represented to the committee.
Modifications are highlighted in Box 4.
Following consultation with experts, no additional pre-testing was required.The V f was then back translated (Box 5) and shared with the developers for their review. 6They expressed satisfaction with the results and did not propose any further modifications.Thus, the V f was the final translation of the HAAS, i.e., the HAAS-Brazil.

DISCUSSION
The functional outcomes of hip and knee arthroplasty can be evaluated using health-related quality of life questionnaires and scales.[3] Consequently, HAAS was developed and validated to assess the functional outcomes of hip and knee arthroplasty surgery in patients who do not experience significant pain or limitations in low-demand activities.Borsa et al. 6 observed that the translation stage inherently initiates the adaptation process.This is because the subjective act of seeking words that accurately convey the intended content and construct inherently involves a degree of adaptation that a literal translation would not capture.Our understanding of translation, informed by a review of the literature, is that it is a component of the cross-cultural adaptation process.Consequently, the terminology used in the title of this paper reflects this concept. 6e initial phase of this study aimed at the cross-cultural adaptation of HAAS to Brazilian Portuguese, during which two translations (T 1 and T 2 ) of the original HAAS questionnaire were generated.Guillemin et al. 11 and Beaton et al. 5 both propose a minimum of two independent translations of the questionnaire or scale into the target language in their methodologies.The translators ideally should be bilingual, with the target language as their native language, to ensure an enhanced ability to discern the nuances and peculiarities of everyday communication within the target language. 5,6,11This approach enables the production of comparable translations, thereby facilitating a more effective evaluation of discrepancies and ambiguities.Furthermore, it is acknowledged that the selected translators should have varied profiles: one with a more technical understanding of the construct in question, and the other, a practitioner with a stronger emphasis on language, even if not necessarily proficient in the essence of the construct. 6erefore, one of the translators who contributed to this work was an orthopedist with prior involvement in cross-cultural adaptation projects, which aimed at developing an adaptation that emphasized clinical equivalence.The second translator was a language professional with a degree in Languages and specialization in translation and communication.This ensured a translation that accurately mirrored the language used by the population, often highlighting ambiguous or excessively broad interpretations within the original questionnaire.
The second step involved merging the two translations into a single synthesized version (T 1,2 ).Borsa et al. 6 identified two potential complications at this stage: (1) a highly complex translation that may be challenging for the target population to understand, or (2) a somewhat simplistic translation that diminishes the content of the item.The research team noted that the original questionnaire's concise, simplified, and objective format could potentially confuse the target population in Brazil.This observation was considered and subsequently presented to the multidisciplinary committee of experts for further deliberation in the subsequent step.
Exemplos: caminhar distâncias curtas para fazer compras 0 Estou recluso em cada (realizo apenas tarefas do lar) sem necessidade de ajuda (máx.18 pontos) The practice and definitions of PA are influenced by the historical context of concept formation, which can that vary based on the cultural context in which they are applied. 12,13Upon acknowledging that the primary objective of the original questionnaire is to assess both motor skill-related PA and sports practice as a skill, the committee suggested conceptual reframing based on available Brazilian sports literature. 12,13This designated a clear line of difference and hierarchy between organized/systematic sports practice and the practice of physical activities of various intensity within the domain (4) Nível de atividade física.Examples: "Competitive sports" for "esportes de alto rendimento com ênfase na competição" and "social sports" for "esportes sociais sem ênfase na competição" (Table 1).
The committee opted to distinguish between sports practice and PA according to energy expenditure and expected motor skill within each degree of participation.This differentiation acknowledges that there is a conceptual and practical distinction between these two modalities within the questionnaire structure.
Examples: "vigorous recreational activities" for "atividades físicas vigorosas, " "moderate recreational activities" for "atividades físicas moderadas, " and "light recreational activities" for "atividades físicas leves" (Table 1).Expert consensus agreed that there was a need for modification and inclusion of examples based on the culture of the target population; removal of sports such as skiing and the inclusion of more popular sports in Brazil like surfing and soccer.

Box 5.
Step 5: Backtranslation of HAAS-Brazil High Activity Arthroplasty Score -Brazil Mark with an (X) your highest level of function in each of these four categories.In relation to the language itself, experts proposed the full use of comparative adjectives, as well as the occurrence of abbreviations present in the original questionnaire.The questionnaire now incorporates clearer and more explanatory commands to assist the target audience in completing it accurately.Examples: "select" for "marque um X ou circule, " ">1 hour" for "por mais de 1 hora, " and "e.g." for "exemplos" (Table 1).The proposed changes to T 1,2 by the multidisciplinary committee of specialists, who then produced V 1 for the pre-test step, were adhered to by the quantitative criterion of the CCV. 7rsa et al. 6 recommended conducting the pre-test with the target population, whereas the typical approach, as suggested by Guillemin et al. 11 and Beaton et al. 5 , involves using healthy volunteers for this stage.3]14 Given these perspectives, the decision was made to conduct the pre-test with volunteers.
Traditional empirical methodology suggests a minimum sample size of 30 to 40 volunteers for the pre-test.In this study, volunteers were consecutively selected using the saturation sampling technique.Saturation sampling, a qualitative research method, involves halting the inclusion of new participants when the data starts to show redundancy and is deemed irrelevant for further data collection by the research team.
In this study, we applied saturation sampling, which resulted in a heterogeneous group that aptly represented the Brazilian population's diversity in terms of age, education, and socio-cultural aspects.This approach adhered to the classic methodology proposed by Guillemin et al. 11 and Beaton et al. 5 Following the saturation sampling technique, 10 the recruitment of new volunteers ceased when no substantial or additional contributions were discernible within the data.This cessation point was reached with a total of 46 volunteers.We incorporated the TSTI with a 5-item Likert scale into the pre-test to assess the cultural adaptation of the questionnaire. 9ollowing the initial pre-test, the researchers incorporated several modifications suggested by the volunteers and resubmitted the revised version to the expert committee.A subsequent pre-test was deemed unnecessary as no significant conceptual or structural changes were proposed. 6Within the TSTI methodology, the active pursuit of critique frequently elicited suggestions that had not been questioned during the examiner's passive assessment of topics.However, on certain occasions, these suggestions, when offered as solutions, risked misrepresenting the intent of a self-administered, objective, and generic questionnaire designed to evaluate the construct of interest.
The fifth step involved a back-translation, a role that has been somewhat debated within the cross-cultural adaptation process. 6The objective was not to achieve a literal equivalence between an adapted version and original versions but rather to maintain conceptual equivalence. 6Despite the debate, we acknowledge that back-translation is an effective tool for communicating and presenting the adapted instrument to the original developers.Consequently, we conducted back-translation as the fifth step, as recommended by Borsa et al. 6 This approach contrasts with the classical methodology of Beaton et al. 5 , which positions this step after the synthesis.The back-translation step was successfully completed, and the results were presented to the developers.They expressed satisfaction with the outcomes and did not suggest any additional recommendations.This marked the conclusion of the sixth and final step in the cross-cultural adaptation process of HAAS into Portuguese, culminating in the creation of HAAS-Brazil.
A notable limitation of this study is the execution of the pretest, which relied on a sample from a single urban center within Brazil.It is important to acknowledge that Brazil, being a continental country, encompasses numerous regional linguistic and cultural differences.To mitigate this limitation, we attempted to assemble a diverse sample of volunteers, considering variables such as education and financial income.

CONCLUSION
The HAAS was translated into Brazilian Portuguese and adapted to the cultural context of Brazil.Our hypothesis that this adaptation is feasible and acceptable in Brazil has been largely corroborated.However, we acknowledge that the validation of the HAAS in Brazil is still ongoing.
tural, and conceptual equivalences between the original version and T 1,2 , thereby identifying necessary adaptations.Consequently, a pretesting version (V 1 ) was produced.The adaptation process was guided by the Coefficient Content Validity (CCV) proposed by Hernandez-Nieto.7

Figure 1 .
Figure 1.Six steps of cross-cultural adaptation: translation, synthesis, review by committee, pretesting, back-translation, and submission of documentation to the developers.

Figure 1 .
Figure 1.Six steps of cross-cultural adaptation: translation, synthesis, review by committee, pretesting, back-translation, and submission of documentation to the developers.

Table 2 .
Main modifications proposed about sports and physical activities Graphic 1. Physical activity practice and sedentary lifestyle among volunteers.Graphic 1. Physical activity practice and sedentary lifestyle among volunteers.

Table 3 .
Descriptive data of pre-test volunteers